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CMN 577 final exam questions & answers
- Knowing that treatment for deep vein thrombosis (DVT) involves the administration of anticoagulants, which of the following patients can be
safely treated for DVT in the outpatient setting? - ✅✅-an 80-year-old
woman who weighs 42 kg B. a 22-year-old man who had an appendectomy 2 days ago C. a 32-year-old woman with peptic ulcer disease D. a 55-year-old man with lung cancer in remission* Most patients with DVT may be treated in the outpatient setting. However, there are multiple contraindications to outpatient treatment, most involving increased bleeding risk, including: active peptic ulcer disease, recent surgery, and weight <55 kg for males and <45 kg for females. Lung cancer or any other cancer that does not involve brain metastases is not a contraindication for outpatient treatment.
- The nurse practitioner is examining a 65-year-old man with a history of type 2 diabetes mellitus and a complaint of cramping pain in his calves when walking. The patient reports the pain is alleviated with rest but returns when the patient must walk again. The nurse practitioner expects to find all of the following on exam consistent with the diagnosis of peripheral artery
disease, except: - ✅✅-weak or absent dorsalis pedis pulses
B. large ulcerations at the medial ankles* C. bruits over the femoral arteries D. an ABI of 0. Peripheral artery disease (PAD) causes intermittent claudication, pulses in the lower extremities to be faint or absent, may cause bruits over the larger arteries, and usually results in an ABI of less than 0.9 (normal is 0.9-1.2). PAD can also cause ischemic and arterial ulcers; however, these are generally found in the toes and feet. Large ulcers near the ankles are characteristic of venous ulcers and chronic venous insufficiency.
- 43-year-old female presents with complaints of weight gain, constipation, memory fog, and fatigue. Her labs reveal a TSH of 6.7 and Free T4 of 5.
Your plan for this patient includes: - ✅✅-Her labs are within normal range,
and no treatment is needed. B. Start her on Synthroid at 1.6mcg/kg/day and recheck labs in 4-6 weeks.* C. Instruct her to take her Synthroid on a full stomach for best absorption. D. Start her on Synthroid at 0.8mcg/kg/day and recheck labs in 2 weeks. Normal TSH values are 0.4-4 mIU/L and normal FreeT4 is 10-27pmlol/L. This patient has both the symptoms and lab values for hypothyroidism. Synthroid (synthetic levothyroxine) is the first line medication for hypothyroidism and starting dose is 1.6mcg/kg/day based on ideal body weight. TSH and Free T4 should be rechecked every 4-6 weeks until euthyroid and normal lab values should be obtained within 1-2 months of starting therapy.
- Cigarette smoking may falsely increase the levels of: -
✅✅-gamma-glutamyl transpeptidase
B. sodium and potassium concentrations C. hepatic enzymes* D. serum protein electrophoresis Cigarette smoking may increase hepatic enzymes which in turn will reduce the levels of substances metabolized by the liver such as theophylline.
- A 75-year-old female patient who is healthy and active reports that she has recently been having trouble getting to the bathroom on time to urinate and also has some leaks when she sneezes or coughs. She reports having to wear an incontinence pad daily. She is very independent and is embarrassed and worried that this is going to affect her lifestyle. As her
provider, your best next steps for this patient would be: - ✅✅-Refer her to
urology, her symptoms will only get worse and she will more than likely need surgery B. Suggest bladder training and pelvic floor muscle exercises (Kegel's) to decrease incidences of stress and urge incontinence * C. Prescribe an antimuscarinic agent such as oxybutynin immediately D. Schedule the patient for insertion of a pessary
- A 23-year-old male patient presents to the clinic with complaints of fever, irritative voiding symptoms, and perineal/suprapubic pain for 2 days. On exam, the CBC shows leukocytosis and a left shift. UA is positive for pyuria and bacteriuria. There is no CVA tenderness or painful scrotal enlargement. The NP suspects the patient has which of the following diagnosis? -
✅✅-Acute Bacterial Prostatitis *
B. Chronic Bacterial Prostatitis C. Acute Epididymitis D. Prostatodynia Acute Bacterial Prostatitis presents with fever, irritative voiding symptoms, perineal and/or suprapubic pain, and a positive UA. Chronic bacterial prostatitis does not present with fever or a positive UA. Acute epididymitis will present with painful scrotal swelling due to enlargement of the epididymitis. Prostatodynia is a noninflammatory disorder presenting with a normal UA and no fever.
- A 24-year-old female who identifies as a lesbian, presents for her annual wellness visit. She has multiple female sexual partners. She did not receive the HPV vaccine and has not had a cervical cancer screening since she was 21 years old. Which of the following is not recommended in the
treatment plan for this patient? - ✅✅-HPV vaccination series
B. Papanicolaou (PAP) smear with HPV co-testing* C. Chlamydia trachomatis and Neisseria gonorrheae testing D. Screen for Intimate Partner Violence (IPV) Chlamydial infections were higher in 14- to 24-year-old women who reported same-sex behavior when compared with exclusively heterosexual women. Untreated chlamydial infection places a woman's future fertility at risk due to potential tubal occlusion. Some women who have a chlamydia infection do not have symptoms. Secondary sequelae of chlamydia include intra-abdominal abscesses, chronic pain, and the need for mul¬tiple surgeries. Regardless of sexual orientation, the CDC recommends annual Chlamydia trachomatis (and Neisseria gonorrheae) screening from the age of first sexual activity to the age of 25 years for all women. Compared to heterosexual women, lesbians and bisexual women have higher exposure to violence throughout their lifetimes. The lifetime prevalence of sexual
assault may be as high as 85%. It is essential to screen all women for IPV but especially those in the LGBTQ community due to these alarming statistics. The primary prevention of cervical cancer is essential. All females between the ages of 12 and 26 years should receive the HPV vaccine series even if they never have been or plan to be sexually active with men. HPV is transmitted sexually between lesbian or heterosexual partners. The rate of HPV immunization among lesbians is significantly less than for heterosexual women, which creates a health disparity that needs to be corrected. While she is due for a PAP smear, the PAP with HPV co-testing is not recommended in women under the age of 30 years old.
- All of the following can help reduce the risk of adolescents developing
STIs except: - ✅✅-a monogamous sexual relationship with one partner
B. the use of a condom C. abstinence D. birth control Abstinence, a monogamous sexual relationship with one partner, and proper condom use has shown to reduce the risk of adolescents developing sexually transmitted infections. On the other hand, birth control only helps to prevent pregnancy and does not offer any protection against STIs.
- A 57-year-old female comes into the clinic with complaints of hot flashes and vaginal dryness. She is a smoker and has hypertension. When giving her hormone replacement options, the NP informs her best option is:
- ✅✅-Oral estrogen B. Oral estrogen with progesterone C. Estradiol injections D. Transdermal estrogen* Transdermal or vaginal estrogen avoids the risks of deep vein thrombosis and ischemic strokes.
- When evaluating a patient with intermittent claudication, the Nurse Practitioner would expect to find all the following except: -
✅✅-Diminished femoral pulses
- Jane is 26 weeks pregnant. Her 50-g one-hour oral glucose tolerance
test results at 164 mg/dL. What is the NP's next step? - ✅✅-start Jane on
metformin B. start Jane on insulin C. order a 100-g oral glucose tolerance test * D. inform Jane that her results are normal Rationale: According to the ACOG, a 100-g three-hour glucose tolerance test should be ordered to diagnosis gestation diabetes for those with a result of >= 140 mg/dL on their 50-g one-hour glucose tolerance test between 24-28 wks gestation.
- A 50-year-old white male presents to the clinic for a recheck of his recent acute attack of Gouty Arthritis. He explains that the gouty attacks occur as a painful, red, and swollen right great toe. He states this has happened several times this year. He was treated for the acute attack, but he is interested in having a medication to take every day to keep this from happening so much. PMH for this patient includes moderate kidney disease. Which is the best way to prescribe Colchicine for this patient? -
✅✅-Colchicine 1.2mg po x 1, then 0.6mg po BID.
B. Colchicine 1.2mg po q day. C. Colchicine 0.6mg po QOD.✱ D. Colchicine 0.6mg po BID. Colchicine is cleared through the kidneys. Patients with moderate chronic kidney disease should take Colchicine once a day or once every other day to be sure to avoid complications from peripheral neuromyopathy or developing colchicine toxicity.
- A 40-year-old woman presents to the clinic for complaints of her hands waking her up at night feeling numb with aching pain. You diagnose her with Carpal Tunnel Syndrome. All of the following are conditions do you commonly see with Carpal Tunnel Syndrome except which one? -
✅✅-Pregnancy
B. Diabetes Mellitus C. Rheumatoid Arthritis D. Lupus ✱
Commonly seen conditions that present with Carpal Tunnel Syndrome are pregnancy, Diabetes Mellitus, and Rheumatoid Arthritis.
- Substance abuse is common in adolescents, what common comorbid condition is seen in adolescents that suffer from substance abuse? -
✅✅-Bipolar disorder**
B. Down syndrome C. Turner's Syndrome D. Epilepsy Rationale: Adolescents who suffer from ADHD, bipolar, depression, and anxiety are more associated with substance abuse.
- You have an adolescent in your office who suffers from bulimia nervosa, mother states therapy did not help and wants to know if there is a medicine that can be prescribed to help the patient stop the cycle. What medication
would you anticipate to start for the patient? - ✅✅-(Alprazolam) Xanax
B. (Amphetamine\Dextroamphetamine) Adderall C. (Fluoxetine) Prozac ** D. Multivitamin Fluoxetine 60mg\day has been proven to break the binge\purge cycle. If Prozac is not tolerated another SSRI can be tried.
- A 32-year-old female comes into clinic with fatigue and dyspnea on exertion. She reports heavy menstrual cycles. She craves and loves to eat ice chips. What abnormal lab values would you find on this patient
diagnosed with iron deficiency anemia? - ✅✅-Serum ferritin level 9ng/mL
B. Hemoglobin 14g/dL C. Serum ferritin level 50ng/mL D. Mean corpuscular volume (MCV): 86fL Ferritin value less than 12ng/mL is a high reliable indicator of reduced iron stores. A ferritin level less than 30ng/mL almost always indicates iron deficiency in anyone who is anemic.
results would support this diagnosis? - ✅✅-Elevated ESR, Elevated CRP
B. Low ESR, Normal CRP C. Normal ESR, Elevated CRP D. Normal ESR, Low CRP Rationale: A normal ESR does not rule out JIA, however, most patients with this diagnosis demonstrate an elevated ESR, CRP, WBC, and platelet count. RF may be positive in some patients, anti-CCP may be detectable prior to RF in some patients.
- The NP is prescribing a patient a medication for pharmacologic prophylaxis of VTE. Which medication requires routine monitoring? -
✅✅-Warfarin*
B. Apixaban C. Enoxaparin D. Aspirin Once the INR has reached the therapeutic range, it should be checked every 6 weeks or more often if needed. The Warfarin dose should then be adjusted according to the INR result and warfarin adjustment guidelines.
- A member of the high school wrestling team has just been diagnosed with a methicillin-resistant Staphylococcus aureus (MRSA) skin infection by his primary care provider. Per his provider's recommendations, he may
return to wrestling practice when: - ✅✅-he may participate at any time if
the lesion is covered B. After at least 24 hours of treatment with appropriate antibiotics C. After 30 days if no new infection occurs D. If no new lesions occur for 48 hours, no moist or draining lesions, and on appropriate antibiotic treatment for at least 72 hours. * Athletes are at high risk of MRSA skin infections through skin to skin contact. Clinical symptoms are localized skin infection or soft tissue abscess. To reduce transmission, he/she must be on antibiotic therapy for at least 72 hours, no new lesions that could indicate worsening infection, and no drainage.
- An evaluation of a patient with an anterior cruciate ligament (ACL)
injury would include: - ✅✅-Lachman test*
B. Drawer test C. Spurling test D. McMurray The Lachman test provides the most accurate information about knee stability in relation to the ACL. The Drawer test is used to evaluate posterior cruciate ligament injuries. The Spurling test is used to evaluate nerve root pain in the cervical spine. The McMurray test is used to evaluate meniscus tears in the knee.
- A 23-year-old male patient presents to the clinic with complaints of pain and swelling to his left knee. Medical history reveals a weekend outdoor camping trip two weeks prior and the patient admits to dysuria. Physical exam results include temperature 100.8, bilateral conjunctivitis, mouth ulcers, and fluid to the left knee without warmth or erythema. When considering the diagnosis of Reactive Arthritis what else should the Nurse
Practitioner inquire about? - ✅✅-Contaminated drinking water
B. Type of fish consumption C. Sexually transmitted diseases** D. Cut or lacerations from a camping trip Reactive arthritis most commonly occurs in young men and usually follows a gastrointestinal illness such as dysentery or sexually transmitted disease. He presents with classic symptoms: fever, ulcers, conjunctivitis, and asymmetric oligoarthritis of weight bearing joint. No gastrointestinal complaints were mentioned, patient should be screened for gonorrhea and chlamydia.
- Mr. Smith is a 78-year-old male that presents to your office with complaints of intermittent, non-significant abdominal pain and fatigue. He mentions that he has just lost his wife. The FNP recognizes these
complaints may indicate: - ✅✅-anxiety
b. constipation c. gastroesophageal reflux disease (GERD) d. depression **
C. "The risks of long-term HRT include heart attack, stroke, gallstones, breast cancer, and increased mortality. These risks are reduced if HRT is started after menopause." D. "There are risks associated with HRT, but they are minimal; therefore, the benefits outweigh the risks." Double-blind randomized control trials have shown that the risks of long-term HRT include heart attack, stroke, gallstones, breast cancer, and increased mortality rates. There is a decreased risk for these occurring if the HRT was started in menopause. It is still generally considered not safe to maintain long-term HRT therapy as the risks do not outweigh the benefits.
- A good clinician understands which of the following principles to be true about using diagnostic tests for diagnosis and management of disease? -
✅✅-If a diagnostic test is positive, the patient definitely has the disease.
B. If a diagnostic test is sensitive for a disease, it can correctly identify patients without the disease. C. If a diagnostic test is specific for a disease, it can correctly identify patients with the disease. D. If a diagnostic test is positive, sensitivity and specificity of the test should be considered along with the patient's clinical presentation.* Rationale: The usefulness of a diagnostic test should not be based solely on their predictive measures (sensitivity and specificity), but also the probability that the patient has the disease. The sensitivity of a test is the ability to correctly identify those with the disease. The specificity of a test is the ability to correctly identify those without the disease.
- A 36-year-old female presents to your clinic with depression, ongoing fatigue, anterior neck tightness without pain, and weight gain. You palpate the thyroid notice goiter and a lumpy texture. There is a positive family history of thyroid problems; mother with hypothyroidism and T1DM. To work up the thyroid for this patient, what lab is specific to your potential
diagnosis? - ✅✅-TSH decreased
B. T4 increased C. TPO elevation*
D. ESR decreased In Hashimoto thyroiditis, antithyroperoxidase (TPO) antibodies will be elevated. TPO is initially checked for diagnosis and should not be routinely checked after initial diagnosis; TSH should be monitored routinely. This patient presents with hypothyroid symptoms thus we anticipate TSH to be increased and T4 to be decreased. ESR is elevated in subacute thyroiditis while antithyroid antibody titers are low. Suppurative thyroiditis both leukocyte count and ESR are usually elevated. Serum FT4 levels tend to be higher than t3 levels due to passive release of stored thyroid hormone, which is predominately T4. In autoimmune thyroiditis, the thyroid gland may be diffusely enlarged, firm, and finely nodular and they may complain of neck tightness, depression, and chronic fatigue.
- A 9-year-old female patient presents to your clinic with her mother. She has a new onset malar rash to her face, two painless ulcers in her mouth, and is complaining of generalized joint pain. The nurse practitioner
completes an assessment. Her NEXT step would be - ✅✅-Order magic
mouth rinse TID to help with pain when eating. B. Refer to Rheumatologist. C. Collect lab work consisting of a CBC, ESR, an ANA panel, and a UA. * D. treat her viral infection with supportive therapies. Systemic lupus erythematous (SLE) is an autoimmune disease. It usually presents in females ages 9-15. One must have 4/11 diagnostic criteria to be diagnosed. Common symptoms are fever, malaise, and joint pain. Others present with a malar rash (butterfly rash across cheeks), discoid rash, joint pain, + ANA, anemia, leukocytopenia, and thrombocytopenia. Once confirmation is made, a referral to a rheumatologist is warranted.
- A 70-year-old male patient is newly diagnosed with Alzheimer disease; the NP would educate the patient and family on all of the following except: -
✅✅-Alzheimer disease is the most common age-related
neurodegenerative disease B. The incidence of Alzheimer disease doubles every 5 years after age 60 C. Short-term memory impairment is early and prominent in most cases of Alzheimer disease
C. Long term use of oral estrogen in women over age 55 have been associated with poorer cognitive performance * D. Women who receive long term estrogen therapy have increased risk for DVT Long term use of oral estrogen in women over age 65 have been associated with poorer cognitive performance.
- A 27-year-old female who is 9 weeks pregnant with a past medical history of hypothyroidism reports to the clinic in need of a Levothyroxine
medication refill. You instruct the patient that - ✅✅-Due to Levothyroxine's
tetroxide effects, it should be stopped and restarted after delivery of infant. B. The dose of levothyroxine should be decreased while pregnant due to slower metabolism of medication. C. She may need to increase the dose of medication after delivery of infant due to stopping medication while pregnant. D. While pregnant she will need an increased dose of Levothyroxine for adequate CNS development of fetus. ** Pregnancy increases the levothyroxine dosage requirement. The need for an increase in dosage has been noted as early as the first trimester (5th week). Medication increase of 20-30% is needed for healthy CNS development particularly in the second trimester. During the postpartum levothyroxine dosage typically returns to pre-pregnancy level. Decreased levothyroxine dose levels is normally required directly following delivery, bilateral oophorectomy, natural menopause, or after cessation of estrogen replacement.
- Mr. Frank is a 76-year-old male who presents to the clinic today with a 3-month log of FBS results. He reports many days of "low numbers" and dizziness. Which of the following medications is likely contributing to his
hypoglycemia? - ✅✅-Metformin
B. Glypizide ** C. Exenatide D. Sitagliptin
Glipizide is a Sulfonylureas with a common adverse reaction of hypoglycemia. Hypoglycemia does not occur with therapeutic doses of Metformin, Exenatide (GLP-1 receptor), and Sitagliptin (DPP-4 inhibitor).
- A 26-year-old female in a strict vegan diet for several years is accompanied by her husband into your clinic with complaints of diarrhea, tingling in hands and feet, and loss of balance. The husband reports new onset of confusion. What should be at the top of the NP's differential
diagnosis based on clinical presentation? - ✅✅-B12 deficiency * B.Folic
acid deficiency C.Iron deficiency anemia D.Autoimmune hemolytic anemia Although it is rare, B12 deficiency can be seen in strict vegans. Signs and symptoms include anorexia, diarrhea, neurologic syndrome, difficulty with balance, dementia, and neuropsychiatric abnormalities. S/S of folic acid deficiency are similar, but it does not affect the neurological status. S/S of iron deficiency anemia: tachycardia, shortness of breath on exertion, brittle and spooning of the nails, smooth tongue, and pica cravings. Autoimmune hemolytic anemia: fatigue, SOB, jaundice, splenomegaly, and may present with angina or heart failure.
- 54-year-old male presents to clinic with bilateral hand pain that is relieved by rest and brief hand stiffness in the morning. He underwent x rays of both hands showing narrowed joint spaces. Based on this, you
suspect: - ✅✅-Lupus
B. Psoriatic arthritis C. Rheumatoid Arthritis D. Osteoarthritis* Osteoarthritis is a degenerative disorder characterized by morning stiffness that is brief, pain relieved with rest, and narrowed joint spaces with increased density of subchondral bone and bony cysts on radiographs.
- A concerned mother brings her 14-year-old daughter into the clinic stating: "I think she is too skinny." The mother tells the NP that her daughter is on the gymnastics team and has lost 10 pounds since she started one
months, and the shoulder is stiff. The pain may decrease but ROM limited. The thawing phase may last a year and movement gradually returns. There is not a refreezing phase.
- You are examining a 30-year-old graduate nursing student who complains of neck pain with numbness and tingling to the bilateral upper extremities, anterior shoulder pain, and headaches. What is your
diagnosis? - ✅✅-Cervical radiculopathy *
B. Rotator cuff injury C. Spondylolisthesis D. Atlantoaxial Instability Cervical radiculopathy can cause neurological symptoms involving C5-7. Patients with neck pain may report associated headaches and shoulder pain.
- The most common location of an ulcer due to chronic venous
insufficiency is: - ✅✅-Lateral aspect of ankle
B. Posterior aspect of the lower leg C. Medial aspect of the ankle* D. Plantar aspect of foot Rational: The most common location of an ulcer caused by venous insufficiency is at or above the medial aspect of the ankle. The patient often has a history of lower extremity edema, itching, and brownish pigmentation of the ankle.
- What is the test usually ordered to manage a Coumadin (Warfarin)
medication? - ✅✅-PT
B. PTT
C. Clotting factor D. INR * INR is the test and the range of 2.3 - 3.0 is considered "in range" and does not require dosage change(s).
- All the following are side effects of using typical and atypical
antipsychotics except? - ✅✅-Dry mouth
B. Delayed gastric emptying C. Urinary frequency** D. Blurred near vision The most common side effects of both typical and Atypical antipsychotics medication are anticholinergic effects such as dry mouth, delayed gastric emptying, blurred near vision, and urinary retention.
- Which of the following diagnostic test are appropriate preventive
screening tool? - ✅✅-PSA for a 60 with no urinary symptoms
B. Mammogram at the age of 35 with no family history of breast cancer C. Cervical cancer screening at the age of 22 who is sexually active. D. CT of the lungs at the age of 55 with no history of smoking. It remains controversial to screen for prostate cancer using the PSA, using a CT of the lung to screen for cancer, or thyroid cancer.
- Your patient has a positive Tinel and Phalen sign on exam. What is your
initial diagnosis? - ✅✅-Olecranon Bursitis
B. Carpal Tunnel Syndrome* C. Dupuytren Contracture D. Medial Epicondylitis A Tinel sign is tingling or shock-like pain on volar wrist percussion. The Phalen sign is pain or paresthesia in the distribution of the median nerve when the patient flexes both wrists to 90 degrees for 60 seconds.
- A 47-year-old female patient presents to the clinic with continuous symmetric swelling of multiple joints, dry eyes and mouth, and palmar erythema. She states her joint pain and stiffness are worst in the mornings. Based on these findings, what is your diagnosis for this patient? -
✅✅-Gouty arthritis
B. Osteoarthritis C. Rheumatoid arthritis* D. Acute viral infection In osteoarthritis, the joint pain is relieved by rest, unlike the pain associated with rheumatoid that is associated with morning joint stiffness. Gouty arthritis is almost always intermittent and monoarticular in the early stages
